• Student pain [ Time Frame: within 5 minutes after vaccination ]
  student self-reported pain during vaccination, rated on a 0-10 scale
• Student dizziness [ Time Frame: within 5 minutes after vaccination ]
  student self-reported dizziness during vaccination, rated on a 0-10 scale
• Student fainting [ Time Frame: within 1 hour after vaccination ]
  student fainting during vaccination, yes/no, as assessed by immunizer
• Student post-immunization stress-related responses [ Time Frame: within 1 hour after vaccination ]
  student post-immunization stress-related responses, yes/no, as assessed by immunizer using the WHO Immunization Stress Responses Criteria
• Utilization of coping strategies [ Time Frame: within 5 minutes after vaccination ]
  use of individual coping strategies during vaccination (distraction, topical anesthetic, privacy, support person, deep breathing, muscle tension), yes/no, as assessed by immunizer using Documentation checklist
• Uptake of vaccination [ Time Frame: by end of school year ]
  proportion of students vaccinated (overall and for each vaccine)
• Implementation success of CARD [ Time Frame: within 3 months of vaccination clinics ]
  perceptions of implementation success of CARD program delivery as reported by CARD implementers (primary targets) using the CARD Global Impression Checklist, individual questions (5-point likert scale, higher number represents better outcome). This information will be supplemented with information from focus groups with implementers and study notes, as well as focus groups with other stakeholder groups (secondary targets - school staff, students, parents)
• Cost of CARD implementation [ Time Frame: within 3 months of vaccination clinics ]
  micro-costing of implementer activities - student education, vaccination clinic, planning for topical anesthetics, re-scheduling vaccinations
• Compliance with CARD [ Time Frame: within 3 months after vaccination clinics ]
  percent compliance with CARD implementation as assessed by implementers using a CARD compliance checklist. This information will be supplemented with information from focus groups with implementers and study notes, as well as focus groups with other stakeholder groups (students, parents, school staff).
• Knowledge of effective coping strategies [ Time Frame: within 3 months of vaccination clinics ]
  knowledge of effective coping strategies, as assessed using a 10-point investigator-developed knowledge test; administered to different stakeholder groups (public health, school staff, students, parents)
• Perceptions about pain and fear [ Time Frame: within 3 months of vaccination clinics ]
  perceptions about pain and fear, as assessed using a 5-point likert scale (higher number represents better outcome) for different stakeholder groups (public health, school staff, students, parents)
• Willingness to be vaccinated [ Time Frame: within 3 months of vaccination clinics ]
  student self-reported willingness to be vaccinated, as assessed using a 5-point likert scale (higher number represents better outcome)
• Fear of needles [ Time Frame: within 3 months of vaccination clinics ]
  student self-reported fear of needles, rated on a 0-10 scale
• Perceptions of Vaccination Program [ Time Frame: within 3 months of vaccination clinics ]
  perceptions of public health staff using the Vaccination Program Global Impression Checklist, individual questions (5-point likert scale, higher number represents better outcome).

The investigators developed a multi-faceted knowledge translation intervention called The CARD System to provide a framework for delivering vaccinations at school that integrates evidence-based strategies to mitigate pain, fear and fainting and promotes a student-centred approach to vaccination. CARD addresses 2 components of the vaccination delivery program: 1) pre-vaccination day preparation and 2) vaccination day activities. In a small controlled clinical trial in a public health unit in Niagara, Ontario, the investigators demonstrated benefits of CARD on student symptoms during vaccination, including fear, and dizziness-precursor of fainting, and satisfaction with CARD by all stakeholder groups (students, public health staff, school staff and parents). This study will evaluate CARD in a large cluster trial in Calgary, Alberta. This trial is the final phase of a 3-phase project, whereby the first 2 phases involve developing an implementation plan for the local context and evaluating feasibility of implementation.

Eight community health centres that provide vaccination services to schools in their regions will be randomized in a 1:1 ratio to CARD or control (usual practices). Data will be collected for vaccination services carried out in grade 6 and grade 9 students in participating schools for the academic year 2019-2020.

• Vaccination; Complications
• Vaccine Adverse Reaction
• Fear

• Experimental: CARD (multi-faceted knowledge translation intervention)
  CARD will be integrated into the school vaccination program. This includes pre-vaccination day preparation (e.g., planning of clinic spaces, student and school staff education about CARD) and vaccination day activities (e.g., clinic set-up, processes for triaging students, implementing pain/ fear/fainting mitigation interventions from CARD during vaccination)
  Intervention: Other: Multi-faceted knowledge translation intervention
• No Intervention: Control (standard care)
  There are no specific procedures being undertaken to plan or execute clinics. Usual practices will be instituted (i.e., no education specific to CARD, nor clinic set-up or execution to incorporate interventions for pain, fear or fainting)

Inclusion Criteria:

• grade 7 and 9 students eligible for vaccination at school
• public health staff in community health centre involved in the study
• school staff in a participating school involved in school vaccination
• parent of a student eligible for vaccination at school

Exclusion Criteria:

- unable to understand and read English